Provider Demographics
NPI:1003043571
Name:SISE, MEGHAN E (MD)
Entity Type:Individual
Prefix:
First Name:MEGHAN
Middle Name:E
Last Name:SISE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 CAMBRIDGE ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2783
Mailing Address - Country:US
Mailing Address - Phone:617-726-5050
Mailing Address - Fax:
Practice Address - Street 1:MASSACHUSETTS GENERAL HOSPITAL
Practice Address - Street 2:55 FRUIT STREET
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114
Practice Address - Country:US
Practice Address - Phone:617-726-2862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-11
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAL-241414207R00000X
MA249274207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS400205948OtherMEDICARE PROVIDER